How to Fight a Medicare Rehab Denial in Maine

Your parent is in a skilled nursing facility getting physical therapy after a hip replacement. The facility says Medicare is cutting off coverage because your parent has "plateaued." But your parent still can't walk to the bathroom. They still can't get in and out of bed safely.

Medicare rehab denials are common, often premature, and almost always appealable. Here's how to fight back.

Why Medicare Denies Rehab Coverage

Medicare Part A covers skilled nursing facility care when the patient needs daily skilled services and is making measurable progress toward rehabilitation goals. The key word is "measurable" — and SNF therapy departments define progress narrowly.

A common denial reason: the facility's therapy team documents that the patient has reached a "maintenance" level, meaning they're no longer improving at a rate that justifies skilled care. But the legal standard isn't just improvement — Medicare must cover skilled services when they're needed to maintain function or prevent decline, not only when the patient is actively getting better. This distinction gets lost in practice.

The Demand Bill Strategy

If a SNF tells you Medicare is stopping coverage and you disagree, ask for a demand bill.

Here's how it works:

1. The facility issues a notice saying Medicare coverage is ending (usually an Advance Beneficiary Notice of Noncoverage, or ABN)
2. You tell the facility: "I want you to submit a claim to Medicare anyway." This is a demand bill
3. The facility submits the claim to Medicare
4. Medicare reviews the claim and either approves it (coverage continues) or issues a formal denial
5. If denied, you now have a formal denial letter — which gives you the right to file a standard Medicare appeal

The demand bill is essential because without it, you never get a formal denial to appeal. The facility just stops billing Medicare and hands you a private-pay invoice. By demanding they submit the claim, you force a reviewable decision.

Medicare Advantage (Part C) Appeals

If your parent is enrolled in a Medicare Advantage plan (like Aetna, United Healthcare, or Humana), the appeal process is different from Original Medicare:

Level 1 — Plan reconsideration. File within 60 days of the denial. The plan must respond within 30 days for standard appeals, or 72 hours for expedited appeals (request expedited when the patient is still in the facility and coverage is ending).

Level 2 — Independent Review Entity (IRE). If the plan upholds the denial, it's automatically forwarded to an independent reviewer within 30 days.

Level 3 — Office of Medicare Hearings and Appeals (OMHA). Administrative Law Judge hearing. Available if the amount in controversy meets the threshold ($180 in 2026).

For Medicare Advantage plans, always request an expedited appeal when your parent is currently receiving services that are being terminated. The 72-hour expedited timeline prevents a long gap in coverage while the appeal is pending.

The NOMNC and QIO Route

If the SNF is terminating skilled services, they must issue a Notice of Medicare Non-Coverage (NOMNC) at least two days before services end. Upon receiving this notice, you can appeal directly to Acentra Health (Maine's Quality Improvement Organization) at 1-888-319-8452.

Filing with Acentra before the coverage termination date keeps services running while the appeal is reviewed. Acentra's clinical panel reviews the medical record and determines whether continued skilled services are medically necessary.

What to Document

When fighting a Medicare rehab denial, build a paper trail:

• Therapy notes: Request copies of all PT/OT/speech therapy progress notes. Look for evidence of ongoing improvement, even if slow
• Physician statements: Ask the attending physician to write a letter supporting continued skilled care
• Functional status changes: Document what your parent can and can't do — specific activities, distances walked, assistance needed
• Safety risks: If stopping therapy would create a fall risk, wound healing delay, or functional decline, document it in your appeal

The Hospital-to-Home Maine guide includes appeal letter templates, a demand bill request script, and a timeline tracker for managing the multi-level Medicare appeal process.

See more Maine guides →